Health seeking for malaria before and after the Health seeking for malaria before and after the implementation of a community-based health implementation of a community-based health

worker strategy: Implications for providing worker strategy: Implications for providing timely and appropriate treatment of malaria?timely and appropriate treatment of malaria?

Obinna Onwujekwe, Nkem Dike, Benjamin Obinna Onwujekwe, Nkem Dike, Benjamin Uzochukwu, Elvis Shu and Paul Okonkwo Uzochukwu, Elvis Shu and Paul Okonkwo

Gates Malaria Partnership LSHTM and Gates Malaria Partnership LSHTM and College of Medicine, University of Nigeria, College of Medicine, University of Nigeria,

EnuguEnugu

Problem statementProblem statementMalaria is the number one public health problem in NigeriaMalaria is the number one public health problem in NigeriaLimited access to good-quality health providers especially in Limited access to good-quality health providers especially in rural areasrural areasPeople with malaria indulge in health-seeking behavior that People with malaria indulge in health-seeking behavior that might lead to wrong diagnosis and inappropriate consumption might lead to wrong diagnosis and inappropriate consumption of drugs.of drugs.Most mothers treat malaria at home, usually with Most mothers treat malaria at home, usually with inappropriate and inadequate doses of drugs & some stop inappropriate and inadequate doses of drugs & some stop medication as soon as fever subsides (Okonkwo et al, 2001). medication as soon as fever subsides (Okonkwo et al, 2001). African Heads of State meeting in Abuja adopted effective African Heads of State meeting in Abuja adopted effective treatment of malaria nearer the home as one of the strategies treatment of malaria nearer the home as one of the strategies for malaria control in Africa (WHO, 2000). for malaria control in Africa (WHO, 2000). Home treatment is the current global focus for provision of Home treatment is the current global focus for provision of near and appropriate treatment of malaria near and appropriate treatment of malaria No evidence that home treatment is the best or the most No evidence that home treatment is the best or the most preferred strategy by consumers for the timely treatment of preferred strategy by consumers for the timely treatment of malariamalaria

Conceptual framework and AimConceptual framework and AimThere could be better strategies than home treatment for providing There could be better strategies than home treatment for providing timely and appropriate treatment of malaria timely and appropriate treatment of malaria Community-based health workers (CBHW) strategy could be Community-based health workers (CBHW) strategy could be effectively used to bring treatment of malaria closer to the homes effectively used to bring treatment of malaria closer to the homes The CBHW would be better able than householders to diagnose and The CBHW would be better able than householders to diagnose and treat malaria and refer the patients when treatment fails and for treat malaria and refer the patients when treatment fails and for complicated malaria complicated malaria Implementation research to determine the processes and outcomes Implementation research to determine the processes and outcomes of a CBHW system for improving the timely treatment of malaria is of a CBHW system for improving the timely treatment of malaria is neededneededThe information is needed for improved timely treatment for malaria The information is needed for improved timely treatment for malaria nearer the homes and reduced delay before seeking formal carenearer the homes and reduced delay before seeking formal care

Aim: Aim: Investigate whether the CBHW strategy could be used Investigate whether the CBHW strategy could be used to improve the provision of near and appropriate to improve the provision of near and appropriate treatment of malariatreatment of malaria

Operational definitionsOperational definitions Home treatment: Home treatment: Malaria treatment undertaken Malaria treatment undertaken by householders without recourse to diagnosis by householders without recourse to diagnosis and/or treatment by trained health personnel.and/or treatment by trained health personnel.Home management: Home management: All actions taken in the All actions taken in the home to manage a malaria case with or without home to manage a malaria case with or without recourse to diagnosis and/or treatment by recourse to diagnosis and/or treatment by trained health personnel.trained health personnel.Community-based health worker:Community-based health worker: A residence A residence of a community (could be an indigene or non-of a community (could be an indigene or non-indigence), who is trained and provides indigence), who is trained and provides treatment for malaria to his/her community treatment for malaria to his/her community members.members.Community-based treatment:Community-based treatment: Treatment that Treatment that is provided within a malaria sufferer’s communityis provided within a malaria sufferer’s community

Study design:Study design: – A prospective study was undertaken in four rural A prospective study was undertaken in four rural

Nigerian villages with all year high malaria Nigerian villages with all year high malaria transmission rate.transmission rate.

The study was conducted in five phases which The study was conducted in five phases which were: were: – (1) the first survey that was used to collect baseline (1) the first survey that was used to collect baseline

data in the four villagesdata in the four villages– (2) the participatory design of the intervention in the (2) the participatory design of the intervention in the

two intervention villages (Adu and Ahani)two intervention villages (Adu and Ahani)– (3) the implementation, supervision and monitoring of (3) the implementation, supervision and monitoring of

the intervention in the two intervention villages the intervention in the two intervention villages – (4) a second survey to evaluate the intervention at the (4) a second survey to evaluate the intervention at the

end of the third phaseend of the third phase– (5) the handing over of the project to the community(5) the handing over of the project to the community

ResultsResultsBefore implementation of CBHWBefore implementation of CBHW

Self-diagnosis was the most common diagnostic method in the 4 Self-diagnosis was the most common diagnostic method in the 4 villagesvillagesPatent medicine dealers (chemists) were the most common source Patent medicine dealers (chemists) were the most common source of treatmentof treatmentMinor use of home treatment and CBHWMinor use of home treatment and CBHWReady drug availability, good quality services and closeness were Ready drug availability, good quality services and closeness were major determinants of care seekingmajor determinants of care seekingCBHW were mostly preferred for provision of near and appropriate CBHW were mostly preferred for provision of near and appropriate treatment of malariatreatment of malaria

After implementation of CBHWAfter implementation of CBHWMarked decline in use of home treatment and increased use of Marked decline in use of home treatment and increased use of CBHW in intervention villagesCBHW in intervention villagesShift of some patients from chemists to CBHW in intervention Shift of some patients from chemists to CBHW in intervention villagesvillagesCBHW still mostly preferred in intervention villagesCBHW still mostly preferred in intervention villages

Table 1: Expressed preference for the provision of near and Table 1: Expressed preference for the provision of near and appropriate treatment before the implementation of CBHWappropriate treatment before the implementation of CBHW

Adu Adu

(N=299)(N=299)

n (%) n (%)

AhaniAhani

(N=298)(N=298)

n (%)n (%)

AmaetitiAmaetiti

(N=300)(N=300)

n (%)n (%)

Enugu-akwuEnugu-akwu

(N=300)(N=300)

n (%)n (%)

Home Home treatmenttreatment

47 (15.7)47 (15.7) 21 (7.0)21 (7.0) 81 (27.3)81 (27.3) 53 (17.7)53 (17.7)

CBHWCBHW 205 (68.6)205 (68.6) 110 (36.9)110 (36.9) 127 (42.3)127 (42.3) 156 (52.0)156 (52.0)

Education to Education to mothersmothers

10 (3.3)10 (3.3) 25 (8.4)25 (8.4) 19 (6.3)19 (6.3) 10 (3.3)10 (3.3)

PHC centresPHC centres 12 (4.0)12 (4.0) 60 (20.1)60 (20.1) 48 (16.0)48 (16.0) 34 (11.3)34 (11.3)

Train Train shopkeepers shopkeepers and PMDand PMD

2 (1.7)2 (1.7) 21 (7.7)21 (7.7) 1 (0.7)1 (0.7) 0 (0)0 (0)

Others (eg Others (eg hospitals)hospitals)

23 (7.7)23 (7.7) 59 (19.8)59 (19.8) 23 (7.7)23 (7.7) 65 (21.7)65 (21.7)

Table 2: Expressed preferences for different providers Table 2: Expressed preferences for different providers for timely and appropriate treatment of malaria after for timely and appropriate treatment of malaria after

implementation of the CBHW strategyimplementation of the CBHW strategy AduAdu

(N=150)(N=150)

n (%)n (%)

Ahani Ahani

(N=148)(N=148)

n (%)n (%)

AmaetitiAmaetiti

(N=149)(N=149)

n (%)n (%)

Enugu-akwuEnugu-akwu

(N=149)(N=149)

n (%)n (%)

Home Home treatmenttreatment

4 (2.7)4 (2.7) 13 (8.8)13 (8.8) 15 (10.1)15 (10.1) 5 (3.4)5 (3.4)

CBHWCBHW 100 (66.7)100 (66.7) 109 (73.6)109 (73.6) 44 (29.5)44 (29.5) 77 (51.7)77 (51.7)

Education to Education to mothersmothers

8 (5.3)8 (5.3) 1 (0.7)1 (0.7) 11 (7.4)11 (7.4) 20 (13.7)20 (13.7)

Treat in Treat in PHC centresPHC centres

23 (15.3)23 (15.3) 18 (12.2)18 (12.2) 37 (24.8)37 (24.8) 28 (18.8)28 (18.8)

Train Train shopkeepers shopkeepers and PMDand PMD

1 (0.7)1 (0.7) 7 (4.7)7 (4.7) 32 (21.5)32 (21.5) 6 (4.0)6 (4.0)

TTable 3: Places where treatment was first sought before able 3: Places where treatment was first sought before implementation of CBHW systemimplementation of CBHW system

RespondentsRespondents AduAdu

(N=139)(N=139)

Ahani Ahani

(N=88)(N=88)

Amaetiti Amaetiti

(N=89)(N=89)

Enugu-akwuEnugu-akwu

(N=104)(N=104)

Home treat.Home treat. 12 (8.6%)12 (8.6%) 8 (9.1%)8 (9.1%) 10 (11.2%)10 (11.2%) 2 (1.9%)2 (1.9%)

Private clinicPrivate clinic 2 (1.4)2 (1.4) 13 (14.8) 13 (14.8) 16 (18.0)16 (18.0) 9 (8.7)9 (8.7)

PMDPMD 68 (48.9)68 (48.9) 28 (31.8)28 (31.8) 30 (33.7)30 (33.7) 40 (38.5)40 (38.5)

CBHWCBHW 2 (1.4)2 (1.4) 13 (14.8)13 (14.8) 18 (20.2)18 (20.2) 21 (20.2)21 (20.2)

HospitalHospital 12 (8.6)12 (8.6) 13 (14.8)13 (14.8) 5 (5.6)5 (5.6) 12 (11.5)12 (11.5)

ChildrenChildren (N=104)(N=104) (N=36)(N=36) (N=38)(N=38) (N=53)(N=53)

Home treat.Home treat. 4 (3.9)4 (3.9) 3 (8.3)3 (8.3) 8 (21.1)8 (21.1) 1 (1.9)1 (1.9)

Private clinicPrivate clinic 11 (10.6)11 (10.6) 4 (11.1)4 (11.1) 4 (10.5)4 (10.5) 2 (3.8)2 (3.8)

PMDPMD 72 (69.2)72 (69.2) 13 (36.1)13 (36.1) 17 (44.7)17 (44.7) 17 (50.9)17 (50.9)

CBHWCBHW 3 (2.9)3 (2.9) 10 (27.8)10 (27.8) 8 (21.1)8 (21.1) 15 (28.3)15 (28.3)

HospitalHospital 10 (1.9)10 (1.9) 3 (8.3)3 (8.3) 2 (5.3)2 (5.3) 6 (11.3)6 (11.3)

Table 4: Places where treatment was first sought after implementation of Table 4: Places where treatment was first sought after implementation of

CBHW systemCBHW system RespondentsRespondents Adu Adu

N=33N=33

Ahani Ahani

N=38N=38

Amaetiti Amaetiti

N=53N=53

Enuguakwu Enuguakwu N=44N=44

Home treat.Home treat. 0 (0%)0 (0%) 0 (0%)0 (0%) 2 (3.8%)2 (3.8%) 4 (9.1)4 (9.1)

Clinic Clinic 6 (18.2)6 (18.2) 15 (39.5)15 (39.5) 9 (17.0)9 (17.0) 3 (6.8)3 (6.8)

PMDPMD 8 (24.2)8 (24.2) 8 (21.1)8 (21.1) 33 (62.3)33 (62.3) 23 (52.3)23 (52.3)

CBHWCBHW 14 (42.4)14 (42.4) 8 (21.1)8 (21.1) 1 (1.9)1 (1.9) 0 (0)0 (0)

HospitalHospital 3 (9.1)3 (9.1) 4 (10.5)4 (10.5) 3 (5.7)3 (5.7) 5 (11.4)5 (11.4)

ChildrenChildren N=47N=47 N=26N=26 N=24N=24 N=25N=25

Home treat.Home treat. 3 (6.4)3 (6.4) 3 (11.5)3 (11.5) 0 (0) 0 (0) 2 (8.0)2 (8.0)

Clinic Clinic 2 (4.3)2 (4.3) 8 (30.8)8 (30.8) 4 (16.7)4 (16.7) 1 (4.0)1 (4.0)

PMDPMD 18 (38.3)18 (38.3) 3 (11.5)3 (11.5) 15 (62.5)15 (62.5) 14 (56.0)14 (56.0)

CBHWCBHW 12 (25.5)12 (25.5) 6 (23.1)6 (23.1) 1 (1.9) 1 (1.9) 0 (0)0 (0)

HospitalHospital 8 (17.0)8 (17.0) 1 (3.8)1 (3.8) 0 (0)0 (0) 1 (4.0)1 (4.0)

CONCLUSION CONCLUSION

Villagers backed up their preferences by actually paying for Villagers backed up their preferences by actually paying for care from the community-based health workers. care from the community-based health workers.

People will not use home treatment and patent medicine People will not use home treatment and patent medicine dealers if there are better treatment options are readily dealers if there are better treatment options are readily availableavailable

Community based workers were most likely to improve Community based workers were most likely to improve rational use of drugs when compared with most providers rational use of drugs when compared with most providers found in the villagesfound in the villages

Improvement in methods of diagnosis (?rapid) and treatment Improvement in methods of diagnosis (?rapid) and treatment of malaria through an enhanced PHC system could be the of malaria through an enhanced PHC system could be the best strategy to improve appropriate and timely treatment of best strategy to improve appropriate and timely treatment of malariamalaria

Increased number and improved quality of trained malaria Increased number and improved quality of trained malaria treatment providers == Improve the healthcare systemtreatment providers == Improve the healthcare system

AREAS FOR FUTURE RESEARCHAREAS FOR FUTURE RESEARCHImplementation research to determine the effectiveness Implementation research to determine the effectiveness of scaling-up the use of CBHW strategy to improve the of scaling-up the use of CBHW strategy to improve the treatment of malaria in rural areas.treatment of malaria in rural areas.

Cost-effectiveness analysis, acceptability and Cost-effectiveness analysis, acceptability and sustainability comparison of CBHW with other means of sustainability comparison of CBHW with other means of treating malaria nearer the homes, such as home treating malaria nearer the homes, such as home treatment in different settingstreatment in different settings

Develop how the CBHW strategy could become part of Develop how the CBHW strategy could become part of the PHC system for its sustainability and enhanced the PHC system for its sustainability and enhanced statusstatus

Funding agency: International Development Research Centre (IDRC), CanadaFunding agency: International Development Research Centre (IDRC), Canada